MiniMedical School

Our second Mini-Medical School was a rousing and informative investigation into the world of organic and fermented food. Dr. Taylor gave a short talk on organics and the health benefits of fermented foods. Kathryn Lukas, owner of Farmhouse Culture, shared a history of sauerkraut and offered a demonstration of kraut preparation and a tasting. For those of you who were not able to attend and for those who were there who need references, here is a summary of our event.

Dr. Taylor spoke about the benefits of organic foods and distributed a flyer from CCOF, one of the two organic certifying agencies in California. The other is “USDA Organic”. There are many reasons to eat organic. Pesticide residues are clearly a risk factor for many diseases and disorders, especially for young and growing children. There are a large and increasing number of scientific studies identifying the risks of pesticides and herbicides. On a larger scale, organic gardening is more sustainable for the earth and will probably prove more resistant to climate change than monoculture. If you ever need to buy conventionally farmed foods the best information is from The Environmental Working Group. The EWG has a useful app for your smart phone (also available to download to print). It is called the “Clean Fifteen and Dirty Dozen” food list at www.ewg.org.

Refrigeration is a relatively recent invention. Although our generation has never known anything else, most of mankind’s history with food preservation utilized smoking, salting, drying and fermenting. Fermented foods that are familiar are sourdough bread, sauerkraut, kimchee, yogurt, kefir, kombucha, but also coffee, cocoa and vanilla.

There are four primary benefits of fermented foods: pre-digestion, nutritional enhancement, detoxification and live bacterial cultures. Pre-digestion occurs when relatively indigestible fibers are broken down to smaller parts that are more easily digested by humans. This also makes some minerals more available. Nutritional enhancement refers to the production of several vitamins by the microorganisms directing the fermentation process as well as other compounds such as nattokinase which appears to have specific health benefits. Cabbage ferments produce compounds that appear to reduce cancer risk. Detoxification of phytates occurs in fermentation. Phytates bind minerals and prevent absorption. There is a fermentation enzyme that releases the minerals bound to grains, legumes, seeds and nuts. Finally, the effect of the live bacterial culture is vitally important. You can take supplemental pro-biotics, but research shows that they colonize the gut somewhat briefly. It is better to think of your bacterial companions as a vast and complex rainforest that you cannot replant with just one or two species. Clearly, it is in your best interest to consume a variety of friendly probiotic foods and supplements to establish a healthy ecosystem. The human cells in your body are outnumbered 10 to 1 by the bacteria in your digestive tract, so being on good terms is very important. Recent research demonstrated improved immune function with a healthy gut flora. This is actually no surprise since a large portion of your immune system is in the gut!

Kathryn Lukas then gave us a masterful presentation of the history of sauerkraut, and a demonstration of kraut making. All of her Farmhouse Culture ingredients are locally sourced, including the salt! It was amazing to see the cut cabbage, coming from the field already colonized with right lactic acid bacteria, develop into a kraut just with the application of salt. We followed the demonstration with a tasting of her creative varieties with Kimchee and Ginger Beet being a big favorite. Farmhouse culture products are locally available at Whole Foods in the refrigerated section. More information is available at www.farmhouseculture.com.

References and resources

Sandor Katz, The Art of Fermentation, 2012, Chelsea Green-A great summary of ferments by a master fermenter and also friend of Kathryn!

For kraut making supplies and a good time Kathryn recommends: Mountain Feed and Farm Supply, 9550 Highway 9, Ben Lomond, CA, www.mountainfeed.com

The recent publication of a study suggesting that mammography is over detecting breast cancer is very confusing to women. The conclusion from the study is that small, localized breast cancers probably never spread, and should not be treated. Unfortunately, we do not have the tools to reliably determine which breast cancers are well behaved and which will become aggressive. It would be inappropriate to generalize from this study and to recommend less frequent mammography. Again, we do not have the knowledge to make a clear recommendation. The Preventive Services Task Force issued a controversial recommendation that mammography should start at 50 and be every two years. That model saves money and procedures, but accepts that some women will be diagnosed later and possibly have a less favorable outcome. That works on paper, but it doesn’t work if you happen to be that one women who was missed in the two year screening cycle. Overall, we just do not have the information we need to make the best choice. This is a decision that is, again, best made between a woman and her doctor.

There is some good news! The KEEPS trial results were announced at the North American Menopause Meeting in October. This study clears much of the confusion surrounding hormone replacement in the menopause. This was a double-blind, placebo controlled study of 700 women ages 41-59, who were healthy and within three years of menopause They were given low dose Premarin orally, or a moderate dose estradiol patch, or a placebo. Women with a uterus were given additional natural progesterone. This trial differs from previous trials in using lower doses and natural, rather than synthetic, progesterone. The hormone therapy group had a reduction in hot flashes and night sweats and an increase in bone density. The group on the patch also had an increase in sexual interest and desire. Measures of cardiovascular risk showed either no change or a modest reduction in risk. There was no increase in breast or endometrial cancer, heart attack, stroke, or deep venous thrombosis. The cognitive studies showed a decrease in depression, anxiety and anger in women on Premarin. This group also has an improvement in recall. The estradiol patch did not have a significant effect on memory.

In summary, this well designed study supports the evolving understanding that hormone replacement works best of given within 3-5 years of menopause. It also adds weight to the preference for natural progesterone rather than a synthetic. Benefit on cardiovascular risk and cognitive parameters are demonstrated with no measurable classic risks, such as breast cancer, after 4 years of observation This study should reassure women who opt for HRT during the menopausal transition.

When faced with conflicting research studies, women should do as much homework as possible and then discuss their thoughts with their doctor. Since not every doctor can follow all the research, you may need to consider consultation with a specialist. This may be money well spent if it leads to a better health outcome. We live in a complex and rapidly evolving world. It is an exciting time to be alive, but for now, we will need to accept a certain degree of uncertainty.

I sometimes hear this question when someone is frustrated by the financial barriers to health care. I believe that applying a business model to healthcare is unwise and dangerous. Essential human services do not perform well as for profit businesses. If profit is the goal, people get crushed in the rush to improve the bottom line and satisfy investors.

Doctors work hard, make a pretty good living and do not have to be worried about being unemployed. Physicians practice medicine because they love to care for people. But, they are usually very poor businessmen and businesswomen. That weakness in finance has been exploited by the payor system, and most physicians are working as employees to satisfy the payor’s demands for a labor force. Physicians, including organized medicine, have not been active enough in defending our patients against the abuses of the for profit economic system. This is a new challenge.

It might be refreshing to review the “Oath” to gain a new perspective. Here is the contemporary version written in 1964 by Dr. Louis Lasagna of Tufts University. I will let it stand on it’s own, but it is clear that there is a mandate to protect the patient and the family’s economic stability. Physicians do not take a vow of poverty. What is called for in the oath is for physicians to confront financial abuses as they occur and protect patients from unnecessary expense.

I swear to fulfill, to the best of my ability, this covenant:

I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow. I will apply, for the benefit of the sick, all measures that are required, avoiding those twin traps of over treatment and therapeutic nihilism. I will remember that there is an art to medicine as well as science, and that warmth, sympathy and understanding may outweigh the surgeon’s knife or the chemist’s drug. I will not be ashamed to say “I know not”, nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery. I will respect the privacy of my patients, for their problems are not disclosed to me that the world may know. Most especially must I tread with care in matters of life and death. If it is given to me to save a life, all thanks. But it may also be within my power to take a life; this awesome responsibility must be faced with great humbleness and awareness of my own frailty. Above all, I must not play God. I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person’s family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick. I will prevent disease whenever I can, for prevention is preferable to cure. I will remember that I remain a member of society with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm. If I do not violate this oath, may I enjoy life and art, be respected while I live and remembered with affection thereafter. May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.

Our second Mini-Medical School was Saturday, May 19th at 12:30, at our usual location, Chautauqua Hall in Pacific Grove.
Here is a copy of the handout with many useful resources.

What is the annual medical exam? It is much more than ordering a pap and a mammogram.
This is what happens at your annual examination for a low risk person (depends on age):
Screening procedure:
Interview:Recent personal medical history, surgeries, new family history; dietary and nutritional assessment; physical activity; use of complementary medicines and practices; tobacco, alcohol and drug use; domestic issues.
Physical Examination: Height/weight/BMI/BP. Physical exam and pelvic examination (usually at >21 years of age).
Laboratory Testing: Pap smear, STD screening, HIV Screening, Blood tests for diabetes and heart disease, mammography, colorectal cancer screening.
Evaluation and Counseling: Sexuality, fitness and nutrition action plan, family, work, lifestyle and sleep, cardiovascular risk factors, injury prevention, sun exposure.
Immunizations: Diphtheria/Pertussis/Tetanus (every 10 years) , Herpes zoster(shingles) (one dose at 60), Pneumococcal Vaccine at 65, Influenza annually beginning at 50, HPV Vaccine (<26 years).
There are many additional tests and screenings for individuals with risk factors, a problem or an illness!You can only decide what is right for you by having an in depth discussion with your personal physician. This summary provides you with a basis for your discussion.

Who sets the standard of care and what are they?
US Preventive Services Task Force http://www.uspreventiveservicestaskforce.org
The American College of Obstetrics and Gynecology http://www.acog.com
Am. Society for Colposcopy and Cervical Pathology http://www.asccp.org

The Pap Smear: Summary: When to start Screening: After age 21. Screening intervals: Every 2-3 years. May screen every 3 years with a history of 3 negative tests. With HPV co-testing (after age 30) every 3-5 years. When to stop screening: Women over 65. With a history of dysplasia screen for 20 years after diagnosis. Screen women over 65 if they are sexually active with multiple partners.

Mammography- Start at age 40 depending on situation. ACOG states every 1-2 years in 40-50 age group and annually thereafter. USPSTF states screening every 2 years. Insufficient evidence of benefit after age 75. Check radiation dose and track exposures at http://www.xrayrisk.com.

Bone Density Screening- Start at age 65, except for high risk groups. High risk is by the FRAX tool ( http://www.shef.ac.uk/FRAX/tool.jsp?country=9 ) defined as smoking, alcohol intake, low body mass, parental fracture history. There are other risk factors, such as amenorrhea, premature menopause, exposure to high risk medications such as steroids.

Other issues- Advanced risk assessment tools (Coronary calcium score, LDL particle count). These may not be covered benefits on your insurance because they are considered “experimental”. This means the insurance company, not the physicians, have decided it is not ready to be used as a screening test.
The professional organizations set the standards based on published and peer reviewed research results. This is considered to be “evidence based medicine”. The decision to pay for testing is usually in the hands of the payor. In the United States, most Americans below the age of 65 are covered by private insurance. Each insurance company has their own approval system and standards for payments. Most private insurance companies are for-profit corporations who are responsible to stock holders. This places the physician between the standard of care and the payor. I believe most patients think their doctor is a representative of their insurance company because they have a contract, whereas the reality is that the physician labor force is simply contract labor.
I choose to step away from that inherent conflict of interest when I cancelled my provider contracts with all the health insurance companies. I do not accept insurance for office visits. Patients pay at the time of service and I courtesy bill their insurance for any out-of-network benefits. It is not easy to be independent, but I can tell you it certainly is honest.

Our first Mini-Medical School of 2012 produced a lively discussion of the Patient Protection and Affordable Care Act. This is the legislation passed early in President Obama’s first term. The law is massive, more than 2,000 pages, and addresses just what the title promises-patient protections and the creation of an affordable health care system. Here are the resources from that Mini-Medical School. You will find several websites that have organized the information in an accessible way. The cornerstone of a democracy is an informed citizenship!

Since the Supreme Court ruled the Affordable Care Act constitutional in June 2012 and will allow it to go forward, there has been quite a fuss from certain quarters. President Obama has applauded to decision and said that it is time for us to let the ACA do it’s work and move forward with other pressing agendas. The congressional opposition does not feel this way and wishes to keep dissent alive. I have listened to their arguments and I do not think they are well informed. I would encourage you to educate yourself about the act using the resources in this handout. I have chosen them to be maximally useful and minimally confusing. I have noticed that much of the rhetoric from the right is identical to the messages sponsored by special interest groups during the Clinton years. You would think they could come up with some new material. This is especially true of ” you will not be able to chose your own doctor”. You can investigate the source of this one by reading DeadlySpin by Wendell Potter. This is an outstanding bit of reporting that exposes the marketing strategies of a major insurance company.

The ACA-where to find out the details. There are several excellent websites that detail the provisions of the ACA.

In 1950, healthcare was 5% of production, now it is 17%. Money spent on healthcare is money not spent on other items, like wages.

Even with our private system, government pays for about half of all healthcare.

The uninsured, who are they? In 2010, 4.5 million people lost employer sponsored coverage. Some were too sick to work. Almost fifty percent of bankruptcies are due to medical expenses and of that group half those people had health insurance. When a patient cannot pay for healthcare, the cost is shifted to the hospital, to insured patients and then to the insurance company, who shift it back to the insured patients. We all pay.

The ACA-where to find out the details. There are several excellent websites that detail the provisions of the ACA.

Popular regulations already in force: No denial of coverage of children for pre-existing conditions, no rescinding of coverage, no lifetime dollar limits on coverage, 85% of insurance premium dollars need to be spent on health care/quality improvement.

We are offering our wonderful Didgeridoo Workshop and Concert again Sunday, September 25th, 2011.

Last March, Stephen Kent gave a great teaching followed by an absolutely stunning concert. If you or a friend have ever wanted to play the didgeridoo, now is the time. There is a beginners workshop (make your own didgeridoo), and intermediate player workshop and then the concert. Admission at the door for friends and family will be $10.00 each.

Didgeridoo playing improves breathing, helps with sleep apnea and snoring, and is just about the most fun you can have. No musical talent required!

Stephen Kent is just back from two very successful European tours. He is a leading light in the didgeridoo world, so give yourself the gift of this experience.

I know many of you are concerned about radiation leaking from the nuclear power plants in Japan. I would like to give you the best links to current and unbiased information. I recommend the Physicians for Social Responsibility website at www.psr.org and also the Union of Concerned Scientists website www.ucsusa.org.

I have been a member of these organizations over that last twenty years and they are the most credible and intelligent sources of information available. I know many of you are considering stocking up on SSKI (supersaturated iodine). This is now in short supply and only prevents thyroid cancer induced by radioactive iodine. It does not prevent other radiation induced cancers. There is a good summary on the Center for Disease Control website on SSKI www.bt.cdc.gov/radiation/ki.asp.

We will just have to wait and see what will progress over the next few days and weeks. We all hold the people of Japan in our hearts and prayers.

Our first Mini-Medical School lecture of 2011 will be Saturday, January 8th at 12:30. Location Chautauqua Hall in Pacific Grove. Many of you have asked for a discussion about food and nutrition. They are not the same! Come with your questions this Saturday. You will have a very interesting time!

The Gulf oil spill has focused our attention on the chemicals in our environment and the long term consequences of chemical exposures. Dr. Taylor will give a lecture reviewing the risks and how to minimize exposure Saturday, August 7th, at 11:30 AM at Chautauqua Hall in Pacific Grove.

Forty years ago, concern over chemical exposures was voiced by a small minority. This changed this year when two very important scientific bodies clearly stated this is not only an issue but an issue of the highest importance. The first was The President’s Cancer Panel Report released April 2010 titled “Reducing Environmental Cancer Risk-what we can do now”. The cover letter to President Obama states clearly that the evidence continues to accumulate linking environmental and occupational exposures and that the public is “increasingly aware of the unacceptable burden of cancer resulting from environmental and occupational exposures that could have been prevented through appropriate national action.”

The second important report is the Scientific Statement of the Endocrine Society titled Endocrine-Disrupting Chemicals, published in Endocrine Reviews, June 2009 and released as a free pdf on the internet. This is a highly technical report but summarizes the ample evidence that endocrine disruptors are implicated in breast and prostate cancer, thyroid function, diabetes and obesity.

Why are these scientific bodies concerned about these apparently exotic chemicals? It is because they are so prevalent and occasionally so persistent. We all know that DDT was banned decades ago, but are still detected in most Americans. Of greater concern, is the clear evidence that newborns and infants have the highest levels.

We do not have a treatment to remove these toxins once they are present. We need to engage the Precautionary Principle and to limit exposure. During the lecture, I will discuss sources of exposure and how to reasonably reduce your risk. We are all looking at big changes in our lives. This is one that we can manage to improve the quality of our lives and our family’s lives.

The Green Guide by National Geographic is excellent and they have just published a guidebook. The cosmetic issue is explored by Women and the Environment at http://www.womenandenvironment.org/

The Center for Disease Control tracks exposure and this report is available at http://www.cdc.gov/exposurereport/
The full 200+ page President’s Cancer Report is available for free at: http://deainfo.nci.nih.gov/ADVISORY/pcp/pcp08-09rpt/PCP_Report_08-09_508.pdf

Should I still get a yearly mammogram and Pap smear? This question is frequently asked during the office day. In the past, it would be assumed the answer would be yes, but some new recommendations have created some confusion.

We will take the Pap smear question first. Several groups make recommendations on the best interval for Pap smear screening. The opinions from the American College of Obstetrics and Gynecology (ACOG) are probably the most influential. There is also another important group called the American Society for Colposcopy and Cervical Pathology (ASCCP). Both organizations have looked at the best intervals for screening. The short version is that a low risk woman can get a pap smear every three years. Low Risk means that she is in a mutually monogamous relationship, has no recent history of abnormal paps and is Human Papilloma Virus (HPV) negative. The virus, HPV, is thought to be the cause of cervical cancer and may be more accurate in predicting progression to cervical abnormalities than the Pap smear itself. I agree with a 3 year interval screening for the Pap smear in truly low risk women. What women are hearing, however, is that they only need to come into the office every 3 years. This is a serious misunderstanding. The annual gynecological exam screens for many other disorders in addition to the Pap smear for cervical cancer. The annual exam screens for breast cancer, vulvar, vaginal and ovarian cancer. I also routinely detect other cancers of the colon and thyroid. It is important to be screened annually for these disorders. You still need your annual gyn exam, you just may not need a bill from the lab for a pap smear.

The mammogram question is still unsettled. The US Preventive Services Task Force created quite a stir when they released recommendations around the time of the healthcare debate. This went to the media when normally it would not be that newsworthy. Basically, they looked at the effectiveness of annual screening starting at age 50 instead of age 40. They also looked at annual screening versus every other year screening. This is common practice in other countries. The unanswered question is whether less frequent screening will still give acceptable detection of early cancers. They based their recommendations on the past 20+ years of breast cancer detection data. The problem is that technology for detection has changed a lot in those twenty years and I believe breast cancer itself is changing. We may not be able to predict future best practice based on data from a different time. Right now the recommendation is for annual mammography in all women starting at age 40. In low risk women, every other year screening in the 40-50 year old age group is an option.

Since good health care is based on relationship, you need to see your provider at least once a year, and more often if you are following a problem. Overall, I believe you will get fewer unnecessary tests if you have a good relationship with your provider. The guidelines are just that-guidelines. The best application of guidelines occurs in the context of a good relationship with a healthcare provider. You want your care custom tailored for you.

Classes and Workshops

Highlighted Events:

Mini-Medical School 2018 We are now meeting at the Unitarian Universalist Church of the Monterey Peninsula, 490 Aguajito Road, Carmel, CA. We meet the first Saturday of even numbered months (except for October) from 1:30 to 2:30 PM.Dates for 2018 are: Jan 20, Medical GeneticsApril 7, Building a Home Herbal Cabinet June 2, The Wheat of Our Ancestors Aug 4, Inside the Disinformation Playbook Oct 13, Genetic Genealogy with Dr. Barbara Rae-VenterDec 1, Genetics Part 2 Bring your questions and your friends!.

Tai Chi 24 Form Yang Style will start Jan 6, 2018. The final 24 Form class of the spring will be May 19th, 2018. A new Essentials Class will start June 23, 2018 and end Sept 29, 2018. Focus will be on Tai Chi Principles using Silk Reeling exercises as primary practice. This class will help prepare you for the October 13-14, 2018, Silk Reeling Workshop. This class is appropriate for both beginners and experienced practitioners. After the Silk Reeling Workshop, regular classes will resume Oct 20, 27, Nov 3, 10, 17, Dec 1, 8, 15, 2018.Tai Chi classes are held in Pacific Grove at 10:30 AM, Saturdays. Call 831-622-1994 for more information and to register.

Silk Reeling Workshop with Sifu Dan Jones. This will be a two day workshop Oct. 13-14, 2018. Call 831-622-1994 for questions and registration.Preregistration required for Tai Chi Classes and Workshops.

Call us at 831-622-1994 to register for Tai Chi Classes and for general information on Tai Chi or the Mini Medical School.

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